evaluation of hormones and trace elements in women with
TRANSCRIPT
Thi-Qar Medical Journal (TQMJ): Vol.(14), No.(2), 2017
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43
Evaluation of Hormones and Trace Elements in
Women with Unexplained Infertility
Khansaa. A. Hussien ,*Prof. Dr. Raid M. H. Al-Salih1 and Prof. Dr. Saher. A. Ali
1Chemistry Dept. / College of Science / Thi-Qar University
Summary
This study aims to Evaluation of prolactin (PRL), thyroid stimulating hormone (TSH),
luteinizing (LH)and Follicle stimulating hormone(FSH)and trace elements (iron and
copper) in women with unexplained infertility (UI). 60 women with unexplained
infertility as well as (40) women with polycystic ovarian syndrome (PCOS) aged (20-
35) year were included in this study. The women were divided according the type of
infertility into primary and secondary groups (1ºUI, 2ºUI, 1ºPCO and 2ºPCO)
respectively. Fifty healthy fertile women with the same age were included in this
study as a control group. The results showed a significant increase in serum of
Prolactin, TSH, LH levels in the two groups of women with explained infertility
(pcos) compared to control and the two groups of women with unexplained infertility.
In contrast no significant differences in Prolactin, TSH, FSH and LH levels in women
with unexplained infertility in comparison with the control.Serum levels of iron and
copper significantly increase in unexplained infertility groups in comparison with
women with explained infertility and control groups. This study concluded that is
Prolactin, TSH and LH hormone are not associated statistically with unexplained
female infertility. The increase in Cu and iron may have an important etiological role
in the pathogenicity of unexplained infertility.
Keywords: Unexplained infertility, PCOS, Hormone, Trace elements, Iron, Copper
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44
Introduction
Infertility is defined as the
inability to conceive naturally after one
year of regular unprotected intercourse.
Most of the time, infertility is some
degree of subfertility in which 1 in 7
couples need specialist help to
conceive. Subfertility can be either
primary or secondary.1Infertility of
unknown origin comprises both
idiopathic and unexplained infertility.
(2,3) Most of the infertile couples have
one of these three major causes
including a male factor, ovulatory
dysfunction, or tubal-peritoneal
disease.(4)
According to the Center of
Disease Control (CDC, 2013), (5)
the
causes of female infertility can be
divided into three broad categories
including defective ovulation, transport
and implantation.(6)
Unexplained
infertility is one of the controversial
subjects in infertility on which
agreement is rarely found among
practitioners. It is a term used to define
30–40 % of couples in whom standard
investigations including semen
analysis, tests of ovulation and tubal
patency have failed to detect any gross
abnormality.(3)
Couples with
unexplained infertility suffer from both
diminished and delayed fecundity. (7)
The diagnosis of unexplained
infertility may be frustrating because if
there is no explanation for infertility,
there is no effective treatment. (7)
The
prognosis is worse if the duration of
infertility exceeds 3 years and female
partner is > 35 years of age. (8)
Treatment has been indicated if the
duration is more than 2 years or the
female partner is > 35 years of age.(8, 9)
Polycystic ovary syndrome (PCOS) is
characterized by hyperandrogenism,
chronic anovulation and polycystic
ovaries. (10, 11)
The prevalence of
classical forms of PCOS is from 6-9 to
19.9% and is even higher in women
with menstrual disorders (17.4-46.4%),
hyperandrogenism (72.1-82.0%), and
anovulatory infertility (55-91%).(12,13)
Clinical symptoms include ovulatory
dysfunction, hyperandrogenism, and
polycystic ovaries. Metabolic disorders
(obesity, insulin resistance, impaired
glucose tolerance, type II diabetes
mellitus, and dyslipidemia) are typical
of 40-85% women with PCOS.(14)
Hormones from pituitary gland like
TSH, prolactin or growth hormone
may act synergistically with FSH and
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LH to enhance the entry of non-
growing follicles into growth phase. In
addition to this, thyroid hormones may
be necessary for maximum production
of both estradiol and progesterone. (15)
It is well known that the function
of the thyroid hormones includes
modulation of carbohydrates, proteins
and fat metabolism, gene expression
and also sexual and reproductive
function and when the thyroid
hormone gets out of balance, many
body functions are affected. (16)
Thyroid dysfunction in females have
been found to be associated with
anovulatory cycles, decreased
fecundity and increased morbidity
during pregnancy. (17)
Hyperprolactinemia also adversely
affects the fertility potential by
impairing the pulsatile secretion of
GnRH and hence interfering with
ovulation. (18)
Moreover it is associated
with menstrual as well as ovulatory
dysfunctions like amenorrohea,
oligomenorrhoea, anovulation,
inadequate corpus leuteal phase and
galactorrhoea. (19)
Hyperprolactinaemia results in
inhibition of gonadotrophin releasing
hormone (GnRH) release pulsatility
from the hypothalamus and subsequent
inhibition of LH and follicle
stimulating hormone, (20, 21)
leading to
inhibition of ovarian function. Chronic
increases in 17b-estradiol also
stimulate prolactin secretion, both
through actions on the pituitary gland
and through hypothalamic
mechanisms. (22)
High levels of
circulating PRL, in physiology and
pathological situations, are known to
cause infertility. (21)
Hypothyroidism can affect fertility due
to anovulatory cycles, luteal phase
defects, hyperprolactinemia and sex
hormone imbalance. (17)
Thyroid
dysfunction is a condition known to
reduce the likely hood of pregnancy
and to adversely affect pregnancy
outcome.
Abnormal patterns of gonadotropin
secretion, including increased serum
luteinizing hormone (LH) concentra-
tions, low–normal follicle-stimulating
hormone (FSH) levels, and increased
LH/FSH ratios have long been
recognized as common characteristics
of women with PCOS. (23)
Trace elements play a vital role in
many different biological functions.
The relationship of trace elements to
different disease states has long been
known. (24)
Although trace elements
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49
are essential components of biological
structures or essential for enzymatic
function, they can be toxic at higher
concentrations beyond what is
necessary for their biological
functions.(25)
Nutritional elements such
as Zn, Cu, and Se are components of
proteins, enzymes and hormones,
which regulate many processes,
including balancing redox reactions,
immune response, and formation of
connective tissue during
development.(26)
Iron is an element essential for life
and maintaining normal organism
function. It is also necessary for the
production of myoglobin, oxidative
phosphorylation within mitochondria,
DNA synthesis.(27)
Copper is normally
bound to proteins as an essential
enzymatic component. In terms of
storage capacity, high concentrations
of Cu are found in liver, which is the
central organ for Cu homeostasis.
(28)Other organs that have high
concentrations of Cu are the brain,
heart, stomach and intestine. Free Cu+
is a potent oxidant causing the
generation of ROS in cells. Thus, the
tight regulation of Cu homeostasis is
required to maintain Cu uptake,
transport, storage, and excretion
activities. (29)
Patients and Method
This study has been conducted at
AL-Hussein Teaching Hospital in Thi-
Qar, Biochemistry Laboratory in
College of Science, at the period
between 10/8/2016 to 25/5/2017.
Informed consent was obtained
verbally from all participants. A total
of one hundred women with infertility
of the ages 20 – 35 years. The women
are already diagnosed as infertile
women by the consultant medical staff,
according to clinical examination and
symptoms. To compare the results,
fifty healthy age matched females with
a history of at least one child birth
were also enrolled. The present study
included (150) females, which divided
into two general groups:
1. Control group: included (50)
apparently healthy Fertile women.
2. Case group: included (100) infertile
women
.
Table(1).Details of numbers and age of the studied groups
Groups
No. Rang of Age (year)
Patients (infertile women) 100 20- 35
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49
Control ( fertile women) 50 20-35
Total 150 20-35
Also the women in this study were divided into subgroups according to type of
infertility of infertile women showed as followings:
1- (1ºUI): included (30) woman with primary unexplained infertile women.
2- (2º UI): included (30) woman with secondary unexplained infertile women.
3- (1ºPCO): included (20) woman with primary explained infertile women (PCOS).
4- (2ºPCO): included(20) woman with secondary explained infertile women (PCOS).
Specimen collection
About (5mL) of blood samples was collected by vein puncture using a sterile
disposable syringe in plain plastic tubes. The serum was separated immediately in
order to allow clotting at room temperature. The blood was centrifuged at 3000
revolution per minute (rpm) for 10 minutes and stored in plain tubes at (-20ºC) until
used or immediately analysed.
Determination of Serum Hormones
The Hormones (PRL, TSH, FSH, and LH) are a Full automated quantitative test for
use with Autoanalyzer Cobas e411 instruments were used for the determination of
(PRL TSH, FSH, and LH) in human serum or plasma using Elecsys and Cobas e
immunoassay analyzers.
Determination of Serum Trace Element Concentration
Serum iron concentration was measured according to the method of iron kit. The
used reagents were supplied by (Randox, UK).Serum Cu concentration was measured
according to the method of copper kit (Spectrum, Germany).
Statistical Analysis
The Statistical Analysis System- SAS (2012) program was used to effect of difference
factors in study parameters. Least significant difference – LSD test was used to
significant compare between means in this study.
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44
Result and Discussion
The women with primary and secondary unexplained infertility (UI) had the mean age
of 29.25 ± 6.26 and 33.69 ±6.36 years respectively, and the mean age of women with
primary and secondary explained infertility (PCOS) groups were 25.844 ± 4.47 and
28.44± 4.21 years respectively. The mean age of the control group was 32.28±6.70
years. The women with primary and secondary (UI) had the mean BMI values of
26.44±3.24 and 27.27±4.04 kg/m2 respectively, and the mean BMI values of women
with primary and secondary (PCOS) were 30.77±3.11 and 31.34±4.12 kg/m2,
respectively. The mean BMI value of control group was 64.02 ± 6.96 kg/m2.
Serum Hormones Concentration
Table (2) shows no significant differences in Prolactin, TSH, FSH and LH levels in
the two groups of women with (1ºUI) and (2ºUI) in comparison with the control
group. These results are in agreement with Beyazit et al. 2016 and Verit et al.,
2017.(30, 31)
Also the study found no significant differences in such hormones levels
between the two groups of the women with UI, can be observed.
The same table shows a significant increase in Prolactin, TSH and LH hormone
levels in the two groups of women with explained infertility (1ºPCO) and(2ºPCO) in
comparison with the control group ( p ≤ 0.05 ). These results agree with the results
reported by George and Malini 2014 ; Shah et al. 2017.(32, 33)
The current study shows
a significant increase in Prolactin, TSH and LH hormone levels in the two groups of
women with (PCOS) in comparison with the two groups of women with (UI)
respectively (p≤0.05). This result agrees with the study of Diamond et al. 2017,
(34)while there are no significantly differences in Prolactin, TSH and LH hormone
levels between the two groups of the women with explained infertility (PCOS).These
results are matched with the results of the study of Spandana et al. 2017.(35)
However the results showed no significant differences in FSH hormone levels in
the two groups of the women with PCO in comparison with the control group. it is no
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011
significant differences in FSH hormone levels between the two groups of the women
with explained infertility (1ºPCO) and (2ºPCO) in comparison with the two groups of
the women with unexplained infertility(1ºUI) and (2ºUI) respectively. These results
agree with the two studies of Beyazit et al. 2016 and Mohammed et al. 2016.(30, 36)
Also, no significant differences in FSH hormone levels between the two groups of
women with (PCOS) can be observed.
The high prolactin, TSH and LH levels were found in PCOS women in the present
study. Hyperprolactinemia can cause symptoms similar to PCOS. Reports have
suggested that women with PCOS have elevated prolactin levels. This increased
prolactin may augment by the inhibition of 3beta-hydroxysteroid dehydrogenase
activity or, less often, through selective action on the sulfation of DHEA in adrenal or
extra-adrenal sites. (32)
In many infertility cases, the diagnosis is simply unexplained because a variety of
reasons like lack of ovulation, mechanical stoppage and parental age
etc.(37)
hypothyroidism is defined by high TSH and normal thyroid hormones. (38,39)
Hypothyroidism is one of the causes of ovulation dysfunction in women, resulting in
infertility. (40)
The ovulation can be affected by hormonal imbalance, thyroid disorders
or chronic diseases such as diabetes. (41)
Some women with hyperprolactinemia might
have primary hypothyroidism.
Abnormality of the hypothalamic-pituitary ovarian or adrenal axis has been
implicated in PCOS. Disturbance in the pulsatility of gonadotrophin releasing
hormone (GnRH) results in the relative increase in LH to FSH release. An abnormal
feedback mechanism by ovarian estrogen is blamed to play role in this discriminated
increase in LH release. (42, 35)
Groups NO. PRL
(µU/ml)
TSH
(µU/ml)
LH (µU/ml) FSH(µU/ml)
Control 50 14.5±3.9 b 2.3±0.7
b 3.2±0.9
bc 5.4±1.4
a
1º UI 30 14.5 ±2.9 b 2.3±0.7
b 2.6±0.7
c 5.3±1.2
a
2º UI 30 14.4 ±2.9 b 2.1± 0.6
b 3.6±1.0
b 5.4±1.4
a
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Table (2):-Serum Hormones levels of control and infertile groups
-Each value represents mean S.D values with non-identical superscript (a, b or c
…etc.) were considered significantly differences (P ≤ 0.05). Control: fertile
woman,1ºUI: Primary unexplained infertility,2ºUI: Secondary unexplained
infertility,1ºPCO: Primary explained infertility, 2ºPCO: Secondary explained
infertility, No: Number of subjects, SD: Standard deviation, LSD:Least Significant
Difference.
Serum Trace Elements Concentration
Table (3) shows a significant increase in the concentration of serum Fe in the two
groups of the women with unexplained infertility (1ºUI) and (2ºUI) in comparison
with control group (p≤0.05). Also, it is found a significant increase in the
concentration of serum Fe in (1ºUI) in comparison with (2ºUI), (1ºPCOS) and
(2ºPCO) groups respectively (p≤0.05), but there are no significant differences in the
concentration of serum Fe between (2ºUI), (1ºPCOS) and (2ºPCO) groups
respectively (p≤0.05). The same Table shows no significant differences in the
concentration of serum Fe in the two groups of women with explained infertility
(1ºPCOS) and (2ºPCO) in comparison with control group (p≤0.05).
Table (3) shows a significant increase in the concentration of serum Cu in the two
groups of the women with unexplained infertility (1º UI) and (2º UI) in comparison
with control group (p≤0.05). Also it is a significant increase in the concentration of
serum Cu in the two groups of women with unexplained infertility (1ºUI) and (2ºUI)
in comparison withtwo groups of the women with explained infertility (1ºPCO) and
(2ºPCO) respectively (p≤0.05). While there are no significant differences in the
concentration of serum Cu between the two groups of women with unexplained
infertility (p≤0.05).
The same Table shows a significant increase in the concentration of serum Cu in
two groups of the women with explained infertility (1ºPCO) and (2ºPCO) groups in
1º (PCO) 20 16.3 ± 3.0 a 2.8±0.7
a 8.1±1.8
a 5.3±1.3
a
2º (PCO) 20 16.1 ±3.0 a 2.9 ± 0.8
a 8.0±1.7
a 5.4±1.4
a
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comparison with control group (p≤0.05). But no significant differences in the
concentration of serum Cu (1ºPCO) and (2ºPCO) groups (p≤0.05), can be observed.
This study shows a significant increase in the concentration of serum Fe in two groups
of women with unexplained infertility (1ºUI) and (2ºUI) in comparison with fertile
women. Also, there are a significant increase in the levels of serum Fe in (1ºUI) in
comparison (2ºUI), (1ºPCOS) and (2ºPCO) groups respectively (p≤0.05). This result
disagreement with the study of Alwais et al. 2016.(43)
There are no significant differences in the concentration of serum Fe between
(2ºUI), (1ºPCOS) and (2ºPCO) in comparison with fertile women. This result matched
with the results study of Alwais et al. 2016.(43)
The non-significant differences in the
concentration of serum iron between two groups of women with explained infertility
(1ºPCOS) and (2ºPCO) in comparison with fertile women. This result matched with
the results study of Li et al., 2016. (44, 45)
In this study it is found high concentration of serum iron in women with
unexplained infertility. There are few studies investigated the effect of iron overload
(toxicity) and fertility and even less with regard to female fertility. However, there is a
link between iron overload and female infertility.(46) Excess iron leads to reduced
production of the hormones LH and FSH from the anterior pituitary suggesting
impaired oocyte maturation and low ovarian reserve.(47)
In this study, no significant
differences in serum levels of iron and were observed between the two groups of the
women with (PCOS) and control group. A research conducted by Taghavi et al. in
2009 in Iran on 50 PCOS patients without overweight did not show iron overload in
these patients.(48)
A cross-sectional study of Lim et al. on 578 people in 2016
indicated that the serum levels of iron had no difference between the two PCOS and
non-PCOS groups.(44)
In this study the high concentration of serum Cu in the women with unexplained
infertility reported by the current study matched with the results of study of AL-Saraf
et al., 2005,(49)
but disagreement with results of study of Bawa and Tyagi who suggest
the copper lower in the women with primary and secondary unexplained infertility
than in control subjects and suggest that hypocupraemia may be a factor in the
aetiology of infertility in these women. (50)
Whereas the reported significant increase in
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the concentration of serum Cu in two groups of women with explained infertility in
comparison with fertile women, matched with the results of studies of Kurdoglu et al.,
2012 and Muyan, 2016.(51, 52)
but disagreement with the results of study of Bawa and
Tyagi who suggest the copper lower in the women with primary and secondary
explained infertility than in control subjects.(50)
The elevation in serum copper levels
may directly affect infertility rates by lowering progesterone levels resulting in
annovulation, implantation failure or luteal phase deficits.(53)
Copper has also been
shown to block the absorption of many essential minerals directly involved with
reproductive pathways, especially zinc. (54)
In this work there were high levels of serum Cu concentration in women with
(PCOS) in comparison with fertile women. The PCOS patients also had a statistically
and significantly higher amount of copper than the control group.(52)
The survey
conducted by Celik on copper, homocysteine, and early vascular disease in lean
women with PCOS showed high copper levels in PCOS patients. (55)
A similar result
was obtained by a study on mice.(56)
Previous studies have shown that patients with
PCOS Copper is involved in the metabolism of oxygen and plays an important role in
free radical reactions.(57, 52, 58)
Table (3):-Serum trace elements levels of control and infertile groups
- Legend as in Table (2)
Conclusion
Groups NO. Fe ( mean± SD
Cu ( ) mean± SD
Control 50 82.55 ± 15.79 c 105.11±21.38
c
1º UI 30 125.01 ± 24.28 a 188.06±56.40
a
2º UI 30 114.69 ±26.36 b 175.24±43.00
a
1º PCO 20 84.03 ± 5.65 c 121.41±17.52
b
2º PCO 20 84.30 ±7.64 c 120.15±15.93
b
LSD 7.66 14.43
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This study concluded that is Prolactin, TSH and LH hormone are not associatedwith
unexplained female infertility. The increase in Cu and iron may have an important
etiological rolein the pathogenicity of unexplained female infertility.
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019
تقذير الهرهىًاث والعٌاصر الٌذرة لذي الٌساء الوصاباث
بالعقن غير الوفسر
أ. د. رائذ هعلك حٌىى الصالح م . م. خٌساء عىدة حسيي
أ. د.ساهر عبذ الرضا علي
الخلاصت
هسمىن الخبُط (،TSH) (، هسمىن ححفُص الغدة الدزقُتPRL) هسمىوالحلُب حهدف هري الدزاظت إلً حقُُم
(LH وهسمىن )ٍخحفُص الجسَبال (FSH)الحدَد والىحاض( فٍ الىعاء دزةالعىاصس الى . اظاقت الً حقُم(
مصابت ( امسأة 06ومرلل ) مفعسعقم غُس مصابتبالامسأة 06حم حعمُه . UI)) المفعسالعقم غُس المصاباحب
حم حقعُم .( ظىت53-06بُه ) هاللىاحٍ حخساوح أعمازهفٍ هري الدزاظت و (PCOS)المباَط مخلاشمت حنُط ب
ºPCO , 2ºPCO)ت عقم اولٍ و مجمىعت عقم ثاوىٌ مجمىع الًوفقا لىىع العقم العقُماث الىعاء
,2ºUI,1ºUI.)ممجمىعت الىعاء العقُماث ىفط عمسحت بخمعُه امسأة خصبت صحُ مرلل حعمىج الدزاظت
فٍ مجمىعخٍ الىعاء ,PRL ) TSH, (LHفٍ معخىي الهسمىواثبُىج الىخائج وجىد شَادة معىىَت .ظُطسة
العُطسة ومجمىعخٍ الىعاء اللىاحٍ َعاوُه مه العقم غُس مجمىعتمقازوت ب( PCOSاللىاحٍ َعاوُه مه عقم )
فعسالعقم غُس الم ذواثفٍ الىعاء ,PRL ) TSH, (LH فٍ فسوقاث معىىَتفٍ المقابل لا حىجد .المفعس
Thi-Qar Medical Journal (TQMJ): Vol.(14), No.(2), 2017
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019
معخىَاث الحدَد والىحاض فٍ مما بُىج الىخائج ان هىاك شَادة معىىَت فٍ .العُطسة مجمىعت بالمقازوت مع
وخلصج هري الدزاظت .المفعسالعقم ذواثالىعاء و العُطسة مجمىعت بالمقازوت مع فعسالعقم غُس الم جمىعخٍم
.حشخسك باحداد مسض العقم غُس المفعس لدي الىعاءلا PRL,TSH, LH, FSH ) ( هسمىواث إلً أن
.احداد مسض العقم غُس المفعس لدي الىعاء الىحاض قد َنىن لها دوز معبب مهم فٍوالحدَد معخىَاث الصَادة فٍ